Endoscopic reversal of the modified Long vertical gastroplasty.

Endoscopic techniques are revolutionizing bariatric surgery because of the significant risks that obesity places on both anaesthesia and surgery. Due to the high number of long-term complications that may be associated with bariatric surgery, and the relative safety of endoscopy compared to operative management, endoscopic methods for reversal of previous bariatric techniques are becoming the favoured approach. We describe the use of an endoscopic stent to assist with endoscopic reversal of a modified Long vertical gastroplasty. The modified Long vertical gastroplasty was a restrictive bariatric procedure that was effective to promote weight loss, but had adverse effects including dysphagia, reflux, indigestion and weight regain. The use of an adjunct stent not only treated the patient's reflux by dilating the stricture but allowed for erosion of the sutures intra-luminally to be removed endoscopically. The endoscopic reversal of this technique is safe and helped to relieve the patient's symptoms of reflux and dysphagia.

Case report: doing the mesenteric twist.

A 23 year old female presents with an internal hernia after undergoing a laparoscopic duodenojejunostomy for superior mesenteric artery syndrome. This is an extremely uncommon complication. On review of the literature and this case, it is hypothesized that the internal hernia happened in this case due to the longer than usual distance between the duodenojejunal flexure and the part of jejunum brought up to anastomosis.

Case report: gastric sleeve surgery leads to new onset Crohn's disease.

We report on the case of a 23-year-old male, who developed diffuse gastrointestinal Crohn's disease 2 months after gastric sleeve surgery. Prior to the surgery this patient had no previous symptoms of an inflammatory bowel disease (IBD). His only risk factor for IBD was a positive family history and he was otherwise well. As bariatric weight loss surgery becomes more widely practiced, there have been multiple sources indicating a possible causal link between bariatric surgery and new onset Crohn's disease.

Weight loss and complications of the banded Roux-en-Y gastric bypass: lessons learned from a prospective case control study.

OBJECTIVE: Obesity is a growing global health burden which is particularly challenging to manage. Bariatric surgery is considered the most effective means of sustained weight loss, and Roux-en-Y gastric bypass is considered the most effective treatment for morbid obesity. The additional benefit of placing a non-adjustable band to form a banded Roux-en-Y gastric bypass has gained interest as a measure to improve weight loss; however, comparative data are few, and complications can be high. METHODS: We conducted a prospective case-control study of 484 patients aged 18 and over who received either banded Roux-en-Y gastric bypass with a non-adjustable silastic ring or Roux-en-Y gastric bypass. Patients were followed up for five years and evaluated for weight loss, percentage excess weight loss (%EWL), BMI, and band-related complications. RESULTS: No significant difference was detected in %EWL or BMI between BRYGB and RYGB. The mean raw weight loss, %EWL, and BMI for BRYGB verse RYGB were as follows: 27.49 SD (17.11) kg verse 34.46 SD (18.18) kg, 65.7% SD (30%) verse 62.2% SD (37%), and 32.33 SD (6.9) kg/m2 verse 32.43 SD (7.2) kg/m2. A total of 80 (21.7%) patients had the non-adjustable band removed for complications. CONCLUSION: There is little difference in weight-loss results when comparing BRYGB to RYGB and non-adjustable bands may cause significant complications.

Use of lumen-apposing metal stents (LAMS) in the management of gastro jejunostomy stricture following Roux-en-Y Gastric Bypass for obesity: a prospective series.

BACKGROUND: Chronic strictures following Roux-en-Y Gastric Bypass (RYGB) are a troublesome complication that can lead to significant morbidity. The use of stents has been described but the need for X-ray and risk of migration have meant limited use in the management of these strictures. Lumen apposing metal stents (LAMS) have traditionally been used for management of pancreatic pseudocysts. They don't require X-ray and are easy to deploy with a short learning curve. This paper explores the use of LAMS to treat post RYGB strictures and explores their safety and efficacy. METHODS: A prospective study over a 4-year period looking at 14 patients with post RYGB strictures. These patients were privately insured patients operated within a tertiary Private facility. The patients were followed up for between 1 and 3 years. We have prospectively collected data on the efficacy and safety of LAMS in these patients. Patients were followed up until stent removal or definitive surgery to correct a stricture. RESULTS: 421 patients underwent RYGB in the study period. 14 (3.3%) of these patients developed a stricture that resulted in insertion of LAMS. There was no immediate complications and 12 patients had complete resolution of their stricture. There were no reoperations due to migration related issues although a migration rate of 19% was noted. 2 patients required surgery to correct refractory strictures not relieved by a LAMS stent, both of these were strictures associated with marginal ulceration of the gastro jejunostomy. CONCLUSION: LAMS are a safe and effective method to manage post RYGB strictures. They have a high rate of resolution of strictures and can be safely deployed across strictures with no immediate complication. Migration does still appear to be a problem, however, does not appear to affect patient outcome or increase morbidity. Insertion is straightforward and doesn't appear to be associated with a long learning curve.

Preventing Peterson's space hernia using a BIO synthetic mesh.

BACKGROUND: Internal hernias occur after Roux-en-Y gastric bypass surgery (RYGB) when small bowel herniates into the intermesenteric spaces that have been created. The closure technique used is related to the internal hernia risks outcomes. Using a non-resorbable double layered suture, this risk can be significantly reduced from 8.9 to 2.5% in the first three postoperative years. By closing over a BIO mesh, the risk might be reduced even more. SETTING: Two large private hospitals specialized in bariatric surgery. METHODS: All patients receiving a RYGB for (morbid) obesity between 2014 and 2018 were included in this retrospective study. In all patients, the entero-enterostomy (EE) was closed using a double layered non-absorbable suture. In 2014, Peterson's space was closed exclusively using glue, the years hereafter in a similar fashion as the EE, combined with a piece of glued BIO Mesh. RESULTS: The glued RYGB patients showed 25% of patients with an internal hernia (14%) or open Peterson's space compared to 0.5% of patients (p < 0.001) who had a combined sutured and BIO Mesh Closure of their Peterson's space defect. Although this was an ideal technique for Peterson's space, it led to 1% of entero-enterostomy kinking due to the firm adhesion formation. CONCLUSION: Gluing the intermesenteric spaces is not beneficial but placing a BIO Mesh in Peterson's space is a promising new technique to induce local adhesions. It is above all safe, effective and led to an almost complete reduction of Peterson's internal herniations. In the future, a randomized controlled trial comparing this technique to a double layered, non-absorbable suture should give more insights into which is the optimal closure technique.